Because of how strong and long-lasting the healthcare system has been in the UK, including the NHS, hospitals, chemists and GP clinics, it is sometimes difficult to see that the modern pharmacy system as we know it came as the result of a lot of very unusual events.

The Great Plague of London, the last and worst of the bubonic plague epidemics in the UK, led to apothecaries taking care of people who could not leave whilst physicians escaped to safety.

This led to a dispute about the role of apothecaries, The Rose Case and the slow development of what became general practice.

However, a surprisingly pivotal moment in the history of medicine involved a bag of sweets, a widespread case of adulteration causing inadvertent poisoning and a man named Humbug Billy.

The Ballad Of Humbug Billy

In the 19th century, very few medicines, drinks or food were subject to quality standards, with the only major exception being beer. As a result of this, adulteration was extremely common and got worse as cities grew ever denser.

In the world of confectionery, it was even worse; using an adulterant such as gypsum, alum or chalk was seven times cheaper than using sugar by volume, so it became very common to mix sugar with adulterants and hope nobody would notice.

One such confectioner was Joseph Neal of Stone Street Bradford, who tended to use powdered gypsum, justifying it by saying that everyone else did.

He made peppermint lozenges for sweet stall owner William Hardaker, better known as “Humbug Billy”.

The week before the fateful poisoning, Mr Neal had run out of gypsum, often known as “daft” in the Bradford trade, and sent his lodger to go pick some up five miles away in the town of Shipley.

When he arrived, the usual druggist Charles Hodgson was unwell so his apprentice took the order for gypsum instead. Only instead of five kilograms of “daft”, he accidentally took powder

from an identical barrel containing arsenic trioxide.

This led to Mr Neal making the lozenges, feeling ill, and delivering them to Mr Hardaker. He got a discount due to the different colours and sold them at the Saturday market.

The result was 200 people falling ill and 20 people dying; each sweet contained between twice and four times the lethal dose of arsenic. It caused vomiting fits and abdominal pain similar to those found during the cholera pandemic.

Ultimately, whilst Mr Hodgson, his apprentice and Mr Neal all stood trial, all were found not guilty, the judge deciding that none of them had a case to answer for.

Mr Hodgson was not involved at all, his apprentice was simply following orders and genuinely did not know the difference, and Mr Neal worked in good faith that Mr Hodgson had supplied him with what he ordered.

The poisoning, the deaths and the fact that nobody faced prosecution led to calls to stop similar poisonings from occurring, being the public cause celebre that led to several changes in the law, most notably the Pharmacy Act 1868 that limited dangerous drugs and poisons to be sold only by qualified pharmacists.